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'Virtual Iraq' Combats Horrors of War for Troops with PTSD

By John J. KruzelAmerican Forces Press Service

WASHINGTON, Sept. 25, 2008  The aroma of roasted lamb rubbed with saffron wafts from a bazaar that begins to empty as the sun sinks between a pair of minarets. A soldier walks past a veiled woman, her eyes peering through a thin slit in an ink-black headscarf. The call to prayer beckons from a lone mosque in the parched, desert town.

Army Col. Michael J. Roy, who oversees the "Virtual Iraq" exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator that represents a new form of PTSD treatment with Army Sgt. Lenearo Ashford, Technical Services Branch, Uniformed Services University, on Sept. 16, 2008, in Washington, D.C. Defense Dept. photo by John J. Kruzel(Click photo for screen-resolution image);high-resolution image available.

Graffiti on a nearby wall catches the soldier's eye and he moves closer, recognizing the mustached face of Saddam Hussein. The iconic image is what remains after a cardboard stencil was dusted with a cloud of red spray paint and peeled off the sandstone.

Just then the undulating notes of the prayer call are shattered by far-off shouting: "Get out of my country you imperialist American!" The soldier cranes his neck and traces the gruff voice to a rooftop. He finds the silhouette of a man shouldering a rocket-propelled grenade launcher and senses the weapon's crosshairs on his camouflaged body.

Thousands of miles from Iraq, this war scene unfolds in a windowless room in the psychiatric wing of Walter Reed Army Medical Center. In the corner sit three computers, one with cords linking it to a pair of goggles, a set of stereo headphones, and machines that generate motion and scent. Using this equipment, doctors are morphing the hellish memories of troops afflicted with post-traumatic stress disorder into an interactive experience called "Virtual Iraq."

A study released in April found that nearly 20 percent of Iraq and Afghanistan veterans report PTSD symptoms, which cover a range of emotional and behavioral changes aimed at blunting the effects of trauma. Now some medical experts believe troops can learn to release the grip of their demons by confronting them face-to-face through this cutting-edge form of exposure therapy.

"You feel like you're going to die: Your heart's beating out of your chest, your blood pressure's going up and you want to just get away from it all," Army Col. Michael J. Roy, a medical internist and director of Military Internal Medicine who oversees Virtual Iraq, said of the treatment. "But you can make it through it. And you realize you're going to be OK."

The traditional form of PTSD treatment is known as "imaginal" therapy. In an average session, patients may be asked to close their eyes and provide a first-person account of their traumatic recollection as thoroughly as memory allows: what they saw, smelled, and heard. But instincts often bar subjects from willingly revisiting these terrifying moments in vivid detail.

"It works well for those who can do that, but one of the cardinal features of PTSD is avoiding the trauma," Roy said. "So you're asking somebody who wants to avoid any reminder, 'Tell me everything you can about what happened.'

"If you can do that, great -- there's a good chance you're going to be cured. But are you going to be able to do it? Are you going to put up with it and keep coming back? A lot of people don't."

Though it’s still in the early test phases, Roy and a team of therapists at Walter Reed hope to show the medical community that virtual reality exposure therapy can be more effective than its classic counterpart.

So what is the starkest contrast between the methodologies of imaginal therapy and Virtual Iraq?

"We're deliberately creating some anxiety," Roy said. “To once again witness a battle buddy getting shot, or smell the residue of a roadside bomb dredges up memories more quickly and in greater detail than merely talking.

"You really do need to create some degree of stress or anxiety for this approach to work," Roy said. "It basically helps to remind the subject of what they felt, and then they remember all kinds of elements that were either suppressed or hard for them to describe."

Virtual Iraq works somewhat like a backhoe, pulling buried memories to the surface by their roots. But the therapy is far from an instrument of penetrating force. On the contrary, one of the computers acts as a physiological feedback loop, safeguarding against experiences that are too emotionally high-charged.

From the back of this machine runs cables that stick to the patient, monitoring blood pressure, heart rate, and levels of perspiration and respiration. The virtual landscape builds piecemeal, and the therapist keeps watch of the physiological readouts as new cues, like gunshots and mortar explosions, are added incrementally.

Meanwhile, a specialist intermittently asks the patient to gauge his levels of distress. The philosophy is that each experience should progress as quickly or slowly as is medically sound, striking a balance between comfort and anxiety.

Perhaps no piece of Virtual Iraq hardware symbolizes this paradox as well as the replica M-16 control device.

"Some troops said, 'Hey, I'm walking through here but I don't have a gun in my hand. When I'm on patrol, I've got a gun in my hand,’" said Roy, explaining why troops have the choice of a handheld joystick or lifelike assault rifle with built-in controls -- a kind of semi-automatic security blanket.

The vulnerability that lies at the heart of PTSD demands that therapists tread carefully while administering treatment. The disorder occurs in the wake of life-threatening events, from surviving an ambush or car crash, to witnessing a fatal accident. While it's normal for a person affected by trauma to have nightmares or flashbacks of the event, PTSD is defined by symptoms that persist longer than one month.

In addition to avoidance, hallmark characteristics of the disorder fall under two categories: hypervigilance and, somewhat paradoxically, numbing.

Michael Bradley, a former Army staff sergeant with the Army's 4th Infantry Division, was diagnosed with PTSD after narrowly surviving a roadside bombing and mortar attack in Baqouba, Iraq, last year. His escalated feeling of vigilance became manifest while vacationing at an amusement park after returning home.

"I went to Disneyland, and the cannons starting firing off the ship," Bradley recalled in an interview. "And here I am low-crawling across the ground, knowing full well that I'm in Disneyland, but my body's reacting.

"My mind is saying, 'Get up, you fool!’ But my body's saying, 'No. I'm not going to do it.'"

Experts believe the parts of the brain affected by PTSD are the amygdale and anterior cingulate gyrus, sections that regulate aggression and fear, and avoidance and numbing, respectively. Though the understanding of its neural pathways has evolved greatly, records of PTSD trace their roots as far back as Homer's ancient Greek epic poem the Iliad, when the protagonist Achilles hears about the death of his closest companion, Patroclus.

Despite its various names -- shell shock, battle fatigue -- and the prospect of even better treatment in the future, it seems PTSD is likely to remain part and parcel of human conflict, Roy said.

"No matter how well we prepare our troops, war is not a pleasant thing; it doesn't come naturally to human beings to be faced with killing other human beings," he said. "We're just not wired that way."

But in the meantime, the secret to what could be the next best treatment of PTSD might be inside the last computer in this room. Known around the psychiatric ward as "The Wizard of Oz," this processor controls everything from the sandstorm pelting the soldier's helmet to the body odor he smells.

Roy fires up the machine and places his subject in the driver's seat of an armored vehicle ripping down a pitch-black desert highway. Through the troop's night-vision goggles, the landscape glows electric green. With the omnipresence of a deity, this machine transports a soldier through time and space, back into the far recesses of his mind, where memories steeped in translucent neon fog remain tucked away.

Whistles of AK-47 assault rifle rounds sing past the vehicle. One connects with the front of the car and web-like cracks spread across the windshield. A panicked call cracks over the radio as mortars begin erupting along the unlit ground like landmines. A scream cuts through the interior noise, and the troop swivels his helmeted-head to see the slain body of the soldier in his passenger seat.

Though it's counterintuitive that reliving a moment like this could somehow lead to a breakthrough, evidence culled from soldiers in this stuffy room suggests it does.

"We've had guys who were avoiding going out in public, not using the Metro, not going shopping, not going to sporting events and the movies," Roy said. "Then they go through this, and suddenly they're able to do those things."